An effort to bypass the state legislature and expand Medicaid in Missouri through a public vote is underway.

Photo courtesy of the Centers for Medicare and Medicaid Services

The secretary of state’s office has given approval to documents calling for the move to be circulated in public as a signature petition. If enough people sign the documents, voters will be asked in the November 2018 election if they want a constitutional amendment that would expand Medicaid.

Republican leadership in the GOP dominated legislature has been largely hostile to expanding the provision under the 2010 Affordable Care Act.

The health care law, also known as Obamacare, withstood a Supreme Court challenge to its constitutionality in 2012. But the court, in its decision, rejected the law’s expansion of Medicaid, saying it coerced states into participation by threatening them with the loss of existing federal payments.

31 states and the District of Columbia have expanded the program. The 19 states that have opted against expansion, including Missouri, are mostly led by Republican Governors and legislatures.

Efforts to amend the Missouri Constitution through a public vote are known as “initiative petitions”. The petition approved for circulation in this case asks two questions – whether Medicaid should be expanded, and whether health providers administering the care should be reimbursed at commercial rates.

Medicaid expansion would extend coverage to any person between 19-and-64 years-old who has an income at or below 133% of the federal poverty level. It also includes a provision for family members. The expansion in Missouri would be implemented under the existing health care law passed in 2010.

Members of the public being asked to sign the petition would also see language informing them that the state has estimated that the cost of expansion would exceed $2 billion annually, while revenues to offset those costs are estimated to be $1.8 billion. The document would also note that local governments expect no costs or savings.

Figures from the St. Louis University School of Law Center for Health Law Studies paint a much rosier picture. It projects that Medicaid expansion will save at least $47 million in state tax dollars during the first year, and $348 million over 10 years. Presumably, the savings would be generated by economic activity from the 24,000 new jobs the expansion is projected to create.

Existing traditional Medicaid in Missouri has strict eligibility requirements. The current program covers low-income children, parents, pregnant women, along with disabled and elderly people. Parents in Missouri must have incomes no higher than 19% of poverty level.

50% of traditional Medicaid costs in Missouri are covered by the federal government, with some calculations reaching as high as 60 percent. Medicaid expansion under the Affordable Care Act is 90 percent covered by federal dollars.

Gerald Peterson of Raytown submitted the petition. He says the contention by opponents that the state would be obligated to pick up the costs if the federal government downsized its commitment is bad information. “We’re not obligated”, said Peterson. “We can drop out of this program at any time. And that’s what the petition says. If they change things, we can stop.”

Democrats state lawmakers uniformly support Medicaid expansion along with a handful of Republicans. Democratic Senator Jill Schupp of Creve Coeur has sponsored legislation for the past several years to expand the program. This year her bill was assigned to a committee, but was never given a hearing.

The fact that an initiative petition gets approved for circulation is hardly an indication it’ll appear on the ballot. In 2016, 139 initiative petitions were approved, but a mere six appeared on the ballot. So far this year, 137 have been approved for circulation.

Dave Dillon with the Missouri Hospital Association thinks placing Medicaid expansion on the ballot presents risks for its backers, given that voters overwhelmingly rejected the creation of a state run health care exchange several years ago.

“It isn’t as if when it has been on the ballot, this has always been wildly popular”, said Dillon. “And you can’t know who might oppose it, and how much resource they might put behind that opposition.”

Dillon also notes that even if Medicaid expansion were to pass a public vote, it would face tough implementation from Republicans who’ve been unrelenting in their opposition to the concept. “If it’s going to happen in Missouri, it’s going to have to happen in a way that can pass the muster with a conservative legislature, and now a conservative governor.”

According to a release from Secretary of State Jay Ashcroft’s office, signatures must be obtained from registered voters equal to five percent of the total votes cast in the 2016 governor’s election from six of the state’s eight congressional districts. Those gathering signatures will have roughly six months to do so, as they’ll be due at the secretary of state’s office by May 6th, 2018.